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PubMed1976

Deep vein thrombosis treated with streptokinase or heparin. Follow-up of a randomized study.

Twenty-seven patients with deep vein thrombosis whose primary therapy was randomized between streptokinase and heparin were reevaluated clinically and by ascending venography after a mean period of 7 months. Normal venograms were found in 6 (40%) of the streptokinase-treated patients and in 1 patient (8%) who had heparin therapy. Segmental valve preservation was found in 1 patient from each group. All patients with complete or partial valve preservation became asymptomatic. Vein recanalization without preservation of valves occurred in 18 patients: 8 (54%) of those on streptokinase, and 10 (83%) of those on heparin. At the time of follow-up, 11 of these 18 patients, including 8 who had had prior thrombosis, reported peripheral edema; the postphlebitic syndrome developed in 1. Factors favoring a good outcome of acute venous thrombosis were (1) no prior thrombotic disease, (2) localized thrombosis, and (3) prompt streptokinase therapy.

Adult↗

PubMed1995

Raised leg exercises for leg edema in the elderly.

UNLABELLED: Leg edema is a common problem in the elderly and requires further evaluation and management. METHOD: From October 1990 to July 1992, 245 patients presented to the Cleveland Clinic Florida with leg edema. All patients were counseled about the benefits of twenty-minute, three-times-a-day raised-leg exercises. Fifty seven (57) of the 245 patients were not compliant with this regimen (nonexercise group). Although not true controls, they formed a comparison group for those who performed the exercise regimen. The exercise group was composed of 188 patients with a mean age of 73 +/- 6.8 years, 25 (13%) men and 163 (87%) women; the nonexercise group was composed of 57 patients with a mean age of 71.9 +/- 4.3, 19 (33%) men and 38 (67%) women. Workup for leg edema included: comprehensive history, clinical examination including prostate or pelvic examination, complete blood count, chemistry profile, thyroid profile, electrocardiogram, chest radiograph, and, when indicated, pelvic or leg ultrasound and pelvic computed tomographic scan. The circumference of the leg with the maximum amount of edema was measured initially and on the fourth week. RESULTS: In this study, the common causes of leg edema in the elderly population were venous stasis (63.2%), drug induced (13.8%), and heart failure (15.1%). Postphlebitic syndrome, cirrhosis, lymphedema, lipedema, prostate carcinoma (CA), and ovarian mass were the less frequent findings. Upon comparison of the circumference of leg edema on initial visit and four weeks after, both the exercise and nonexercise groups showed significant decreases in the measurement of the leg edema (P < .001) except those caused by lymphedema.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMedDate not supplied

Endoluminal recanalization in a patient with phlegmasia cerulea dolens using a multimodality approach.

Phlegmasia cerulea dolens, a rare complication of deep venous thrombosis, has traditionally been difficult to treat. The patient described in this report posed additional therapeutic challenges based on a history of heparin-induced thrombocytopenia. She presented with severe leg pain and swelling, and a venogram showed occlusion of both her inferior vena cava and right iliac vein. The use of a multimodality approach, both chemical and mechanical, was successful in removing the venous occlusion, thereby preventing further complications, such as circulatory shock, postphlebitic syndrome, and venous gangrene.

Catheterization↗

PubMed2006

Diagnosis and treatment of deep-vein thrombosis.

Deep-vein thrombosis (DVT) is a common condition that can lead to complications such as postphlebitic syndrome, pulmonary embolism and death. The approach to the diagnosis of DVT has evolved over the years. Currently an algorithm strategy combining pretest probability, D-dimer testing and compression ultrasound imaging allows for safe and convenient investigation of suspected lower-extremity thrombosis. Patients with low pretest probability and a negative D-dimer test result can have proximal DVT excluded without the need for diagnostic imaging. The mainstay of treatment of DVT is anticoagulation therapy, whereas interventions such as thrombolysis and placement of inferior vena cava filters are reserved for special situations. The use of low-molecular-weight heparin allows for outpatient management of most patients with DVT. The duration of anticoagulation therapy depends on whether the primary event was idiopathic or secondary to a transient risk factor. More research is required to optimally define the factors that predict an increased risk of recurrent DVT to determine which patients can benefit from extended anticoagulant therapy.

Algorithms↗

PubMed2004

Thrombotic complications of central venous catheters in cancer patients.

Central venous catheters (CVCs), such as the tunneled catheters and the totally implanted ports, play a major role in general medicine and oncology. Aside from the complications (pneumothorax, hemorrhage) associated with their initial insertion, all of these CVCs are associated with the long-term risks of infection and thrombosis. Despite routine flushing with heparin or saline, 41% of CVCs result in thrombosis of the blood vessel, and this markedly increases the risk of infection. Only one-third of these clots are symptomatic. Within days of insertion, almost all CVCs are coated with a fibrin sheath, and within 30 days, most CVC-related thrombi arise. Aside from reducing the function of the catheter, these CVC-related thrombi can cause postphlebitic syndrome in 15%-30% of cases and pulmonary embolism in 11% (only half of which are symptomatic). Risk factors for CVC thrombosis include the type of malignancy, type of chemotherapy, type of CVC, and locations of insertion site and catheter tip, but not inherited thrombophilic risk factors. Efforts to reduce CVC thrombosis with systemic prophylactic anticoagulation with low-molecular-weight heparin have failed. Low-dose warfarin prophylaxis remains controversial; all studies are flawed, with older studies, but not newer ones, showing benefit. Currently, less than 10% of patients with CVCs receive any systemic prophylaxis. Although its general use cannot be recommended, low-dose warfarin may be a low-risk treatment in patients with good nutrition and adequate hepatic function. Clearly, additional studies are required to substantiate the prophylactic use of low-dose warfarin. Newer anticoagulant treatments, such as pentasaccharide and direct thrombin inhibitors, need to be explored to address this major medical problem.

Anticoagulants↗

PubMed1976

Antithrombotic drugs: part II.

The defibrinating agent ancrod has had limited clinical trial, but appears to give no advantages over heparin. Intravenous infusion of dextran, a glucose polymer, has been shown to have an antithrombotic effect in many experimental models of thrombosis. However, the evidence that dextran is a clinically valuable antithrombotic drug is conflicting. A number of controlled randomized studies have shown that dextran can prevent postoperative venous thromboembolism when a large volume of dextran 40 or 70 was infused rapidly during and after surgery. However, blood volume expansion during dextran treatment prohibits its use in patients with reduced cardiac reserve, and infrequent though sometimes severe, allergic reactions have been reported. Evidence that dextran is of value for the treatment of venous or arterial thromboembolism comes from uncontrolled studies and is not convincing. Many compounds have been shown to inhibit platelet function in vitro but only five of these drugs have been extensively evaluated as prophylactic or therapeutic antithrombotic agents in man. These are aspirin, sulphinpyrazone, dipyridamole, hydroxychloroquine and clofibrate. They have been evaluated mainly in patients with cerebral vascular disorders, coronary artery disease, peripheral artery ischaemia, venous thromboembolism, prosthetic heart valves, and in patients with arteriovenous shunts. The evaluation of the clinical effect of the platelet function suppressing drugs is in its early stages, but they appear to differ from each other in the spectrum of their clinical effectiveness, and they may be more effective in arterial than in venous thromboembolic disorders. Their role in the management of cerebral vascular disease and coronary artery disease is still uncertain, and should be clarified by the results of a number of multi-centre, prospective, randomized studies which are currently in progress. Three types of thrombolytic drugs have been evaluated clinically; the plasminogen activators streptokinase and urokinase, proteolytic enzymes such as plasmin, and agents which increase the level of endogenous plasminogen activator (e.g. anabolic steroids). Of these, the plasminogen activators now have a definite place in clinical practice. The plasminogen activators accelerate the lysis of recent venous thrombi and pulmonary emboli, and of arterial thrombi or emboli. Thrombolytic therapy with these agents should be considered particularly in patients with recent major pulmonary embolism, as lysis of recent emboli is rapid and substantial. It should also be considered in patients with recent extensive venous thrombosis, because total lysis of venous thrombi has been reported to result in long-term preservation of valve function, and is likely to prevent postphlebitic syndrome, though this has not been proven. However, plasminogen activator therapy carries a higher risk of bleeding than heparin treatment...

Anabolic Agents↗

PubMed1989

Use of thrombolytic drugs in non-coronary disorders.

Clinical experience with thrombolytics in non-coronary disorders is limited to the plasminogen activators streptokinase, urokinase and alteplase; therapeutic trials with anistreplase (APSAC) are almost, and with saruplase completely, limited to acute myocardial infarction. In terms of thrombus clearance, thrombolytic drugs are superior to heparin in patients with recent deep vein thrombosis in the pelvis or lower limbs. In aggregate, thrombi younger than 8 days are lysed in approximately 60% of patients treated with streptokinase, urokinase or alteplase. The results of studies assessing the subsequent development of the postphlebitic syndrome are conflicting, but most suggest that thrombolytic therapy can reduce symptoms of chronic venous insufficiency. Currently, the combination of systemic thrombolytic drugs followed by heparin is recommended for patients with acute major pulmonary embolism who are haemodynamically unstable. Streptokinase, urokinase and alteplase have all been shown to accelerate the lysis of pulmonary emboli and to decrease pulmonary vascular obstruction and pulmonary hypertension. Systemic venous or intrapulmonary infusions of alteplase offers the same benefit in terms of angiographic and haemodynamic improvement. A short infusion of 100 mg alteplase over 2 hours seems to be superior to a 24-hour infusion of urokinase. None of the thrombolytic trials in pulmonary embolism have been large enough to demonstrate a reduction in mortality. It is now generally accepted that, unless contraindicated, thrombolytic therapy is the front-line treatment for patients with massive pulmonary embolism and major haemodynamic disturbance. The local treatment of acute arterial occlusion in limb arteries results in rapid clearing of the artery in 67% of patients treated with streptokinase; the corresponding success rates for urokinase and alteplase are 81% and 88 to 94%, respectively. The main question appears to be the identification of patients in whom local thrombolysis is the treatment of choice, as opposed to established therapeutic modalities. Thrombolytic treatment following a major ischaemic stroke is hazardous, although clinical improvement has been noted in a minority of patients with recanalised cerebral arteries. The safety and efficacy of thrombolytic treatment remains unproven for this indication, and its use must be restricted to experimental protocols. Thrombolytic treatment in retinal artery or vein occlusion has, in practice, been abandoned.

Fibrinolytic Agents↗

PubMed2001

Safety of a clinical surveillance protocol with 3- and 6-week warfarin prophylaxis after total joint arthroplasty.

The charts of 1869 patients were reviewed for the occurrence of deep venous thrombosis (DVT) and pulmonary embolism after total hip or knee arthroplasty. Prophylaxis consisted of 3 (group 1; n=1235) or 6 (group 2; n=634) weeks low-dose warfarin, pneumatic compression boots worn by patients in the hospital, mobilization on the first postoperative day, and a clinical surveillance protocol. Venous ultrasound or ventilation/perfusion lung scintigraphy (V/Q) was performed only if patients became symptomatic. patients. Twenty-three (1.8%) patients were positive for DVT. Ventilation/perfusion lung scintigraphy was performed on 25 patients, and 5 (0.4%) patients were positive for pulmonary embolism. In group 2, 117 patients were evaluated for DVT, and 19 (3%) patients had positive results determined by ultrasound. Twenty-five patients were evaluated with V/Q and only 1 (0.16%) patient was positive for pulmonary embolism. No patient developed a fatal pulmonary embolism or postphlebitic syndrome. This prophylaxis protocol is an efficient and cost-effective method for the prevention of significant events after surgery.

Aged↗

PubMedDate not supplied

[Prevention of venous thrombosis: role of heparins].

Prevention of venous thromboembolism is of major importance because deep vein thrombosis is an economic burden. To prevent pulmonary embolism, whether fatal or not, and the postphlebitic syndrome, virtually all patients' level of risk should be assessed in order to provide adequate prophylactic measures against venous thromboembolism. Non-pharmacological, pharmacological or combined modalities can reduce the frequency of venous thrombosis. Evidence-based guidelines are available for most situations in surgical patients. However, in medical patients there are fewer data and there are wide variations of opinion. Systematic reviews should be performed and updated to obtain practice guidelines. Cost and effectiveness as well as patients' preferences should be taken into account. Randomized control trials are ongoing: low-molecular-weight heparins are being evaluated in general medical patients; other forms of prophylaxis or combined methods are also being investigated.

Anticoagulants↗

PubMed1999

[Clinical characteristics of thrombotic diseases of arteries and veins].

Thrombotic occlusion of the arteries and veins are categorized as acute and chronic presentations. Acute arterial occlusion results in severe ischemia because of poor or no development of the collateral arteries. They should be treated promptly by thrombectomy or thrombolysis. On the other hand, chronic arterial occlusion is preferably treated by bypass surgeries. Although the vascular surgeries in the chronic arterial occlusion have undergone remarkable development in the recent years, the treatment of acute occlusion still lags behind poor with prognosis. The treatment of acute venous occlusion is aimed to prevent postphlebitic syndrome except for the ischemic type such as venous gangrene. The purpose of the treatment of chronic venous occlusion is to assist the pump function of the calf muscles to avoid venous stasis. Pulmonary embolism is the most severe complication and its treatment remains controversial.

Arterial Occlusive Diseases↗

PubMed2000

[Annular constriction of popliteal vein for treating severe venous insufficiency].

OBJECTIVE: To study the mechanism and therapeutic effects of annular constriction for severe venous insufficiency of legs. METHODS: Annular constriction of popliteal vein was performed by Gore-Tex vascular graft in 82 patients. Among them, 78 patients had deep venous valve insufficiency of legs (III, IV degree), 2 postphlebitic syndrome, and 2 valve absence of deep vein. Under normal respiration and breath holding, venous pressure was measured at the proximal and distal part from the constricting site. RESULTS: Great difference was noted in the venous pressure between the proximal and distal part from the constricting site. The pressure was (9.4 +/- 4.5) mm Hg, (41.2 +/- 28.1) mm Hg at calm and (32.4 +/- 16.2) mm Hg, (41.2 +/- 28.1)mm Hg at breath holding (P < 0.01). Symptoms disappeared or released after operation. Ulcer healed in all patients. Venous pressure decreased by over 60%. Pressure recovery time was over 22 seconds. There was no reflux distal to the constricting site. Deep venous angiography and color Doppler showed an effect similar to venous valve. CONCLUSION: Annular constriction is effective in treating severe venous insufficiency of legs.

Constriction↗

PubMed1975

[Indications and technics of the surgical treatment in iliaco-femoral thrombophlebitis in the acute phase].

A personal technique employed in the successful resolution of a case of iliacofemoral phlebothrombosis is described. Attention is drawn to the indications for this type of operation. The technique is not traumatic and can be easily performed, particularly with the aid of a Fogarty catheter. The results obtainable as far as the prevention of lung embolism and postphlebitic syndromes are concerned are also described.

Acute Disease↗

PubMed2002

Venous thromboembolic prophylaxis following total hip arthroplasty: a North American perspective.

Patients undergoing total hip arthroplasty are at risk for venous thromboembolic disease, including deep venous thrombosis, pulmonary embolism, and postphlebitic syndrome. The incidence of these complications has declined as a result of recent advances in surgical procedures, early postoperative patient mobilization, and prophylactic alternatives. This paper reviews the benefits and disadvantages of current mechanical and pharmacologic thromboprophylactic alternatives, as well as the prophylactic effects of different anesthesia techniques and of presurgical autologous blood donation. The pharmacologic agents that are widely used in North America today include aspirin, warfarin, and low-molecular-weight heparins. The low-molecular-weight heparins-enoxaparin and dalteparin-have recently gained increasing acceptance among orthopedic surgeons. The effectiveness and safety of extending prophylaxis beyond the time of hospital discharge are also discussed. It is concluded that the optimal thromboprophylactic regimen is one that is customized, adjusted according to each patient's risk factors and other characteristics.

Anesthesia↗

PubMed1992

[Physiopathology of venous stasis at the microcirculation level].

The division of the venous circulation in to two sectors, one constituted by the superficial and deep venous trunks (macrocirculation) and the other by the capillaries and precapillary venules (microcirculation), is surely schematical but aids the comprehension of many hemodynamic effects connected to hampered venous return and to the incompetence of the valvular devices. In fact many of the effects of stasis and venous hypertension (oedema, red cell diapedesis, skin dystrophies) cannot be explained merely by hydraulic mechanisms but require a primary alteration of the microvascular wall associated with structural changes of the perivascular connective tissue. The alterations that occur in microcirculation are of the utmost importance in the formation of the venules ulcerations. The passage of fibrinogen through large pores in the venules of the patients affected by venous hypertension derived from venous insufficiency creates a pericapillary fibrin deposition that cannot be removed because of inadequate blood and tissue fibrinolysis. This accumulation acts as a barrier to the diffusion of oxygen and other nutrients, determining a stasis dermatitis that may lead to tissue necrosis and ulceration. The more precise knowledge of the phenomena connected with the venous stasis at the level of microcirculation (pericapillary fibrin deposition, endothelial ischemia, blocked lymphatic drainage) will not only allow a deeper comprehension of the clinical signs but hopefully will lead to a more effective treatment of the postphlebitic syndrome.

Humans↗

PubMed1992

Lymphatic and venous examination of the ulcerated leg: a preliminary report.

BACKGROUND: It has been widely accepted that deep venous thrombosis and venous incompetence initiate a series of events resulting in various ulcerations. The role of the lymphatic system in the progression of these events has not been extensively studied. METHODS: Twenty-three patients with nonarterial ulcerations of the legs were examined by phlebography and lymphangiography. All had recurrent ulcerations associated with nonpitting edema, brawny induration, and dermatitis characteristic of the postphlebitic syndrome. Arterial circulation was normal in all patients. RESULTS: Phlebographic abnormalities found were the presence of communicating vein incompetence in all 23 patients, varicose veins in six, and deep venous occlusion in one. Lymphatic abnormalities were also present in all patients. Extravasation in the area of the ulcer was seen in eight patients, dermal backflow in six, tortuosity and irregularity of the channels in four, and retention of contrast agent for more than 24 hours in seven. CONCLUSIONS: Significant abnormalities of the lymphatic system exist in patients with leg ulcers caused by the postthrombotic syndrome.

Humans↗

PubMed2004

Current recommendations for extended out-of-hospital thromboprophylaxis following total hip arthroplasty.

Patients who have undergone total hip arthroplasty are at risk for venous thromboembolic disease, including deep venous thrombosis, pulmonary embolism, and postphlebitic syndrome. Although the number of annual total hip arthroplasties in the United States has steadily risen in the past decade, the rate of venous thromboembolic disease within that patient group has declined as a result of advances in surgical and postoperative procedures, including prompt mobilization and safety and efficacy of thromboprophylactic alternatives. This paper reviews the therapeutic options for deep venous thrombosis prophylaxis following total hip arthroplasty, with an emphasis on recommendations of the Sixth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy. The implications of recent randomized clinical trials on care provided by physiatrists in the rehabilitation facility setting are also discussed. The low-molecular-weight heparins have become widely accepted alternatives to aspirin, heparin, and warfarin as results from randomized clinical trials have proved their superior safety and efficacy in the postoperative period. Prolonged prophylaxis up to 30 to 35 days postoperatively in total hip arthroplasty may offer additional protection against venous thrombosis. Therefore, to prescribe optimal thromboprophylactic regimens following total hip arthroplasty, physicians require an understanding of the current recommendations of the Sixth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy and the implications of recently concluded clinical trials.

Anticoagulants↗

PubMed1991

Effort thrombosis: recognition and management while underway.

Effort thrombosis of the axillary and subclavian veins is an uncommon cause of upper extremity swelling. Prompt recognition and treatment of this disorder is important in order to minimize the complications of pulmonary embolism and postphlebitic syndrome that can occur with this condition. This can be very challenging while underway or in the field. A sailor who developed effort vein thrombosis while underway on board the aircraft carrier USS Abraham Lincoln is presented to review the presentation and management of this disorder, particularly as it applies to active duty military personnel.

Adult↗

PubMed1990

Tissue plasminogen activator (rt-PA) vs heparin in deep vein thrombosis. Results of a randomized trial.

We performed a randomized trial comparing two dosing regimens of recombinant tissue plasminogen activator (rt-PA) plus heparin vs heparin alone in the treatment of acute proximal deep vein thrombosis in 83 patients. Of 12 patients who received 0.5 mg/kg rt-PA plus heparin over 4 h, seven (58 percent) had greater than 50 percent lysis of the thrombus, compared with none of 12 who received placebo plus heparin (p = 0.002). Of 28 patients who received 0.5 mg/kg rt-PA over 8 h, repeated in 24 h, six (21 percent) had greater than 50 percent lysis, compared with two (7 percent) of 30 patients who received placebo plus heparin (p = 0.11). The 4-h infusion of rt-PA produced a 40 percent reduction and the 8-h infusion an 11 percent reduction in plasma fibrinogen concentration. At long-term follow-up, three (25 percent) of 12 patients in whom greater than 50 percent lysis was achieved had symptoms of the postphlebitic syndrome, compared with 19 (56 percent) of 34 patients in whom lysis was less than 50 percent (p = 0.07).

Double-Blind Method↗